Category Archives: IPTp

Elaine Roman and Kristin Vibbert of the Jhpiego malaria team describe below an important community-based intervention to prevent malaria in pregnancy. Follow their links to learn more.

The World Health Organization (WHO) 2018 World Malaria Report revealed that of 33 countries where intermittent preventive treatment (with sulfadoxine-

Quality Assured SP Packets

pyrimethamine/SP) is recommended for pregnant women, only 22% of eligible pregnant women received three doses of intermittent preventive treatment during pregnancy (IPTp3) with SP in 2017 (). Therefore, it is crucial that innovative interventions to scale up the provision of IPTp are needed to protect lives of mothers, fetuses and newborns.

The TIPTOP project is implementing a community-based approach to expand coverage of IPTp3 to a minimum of 50% in project areas, helping to reach the hardest-to-reach pregnant women and to ensure there are no missed opportunities for pregnant women to receive QA SP. Through rigorous research and routine monitoring, TIPTOP will generate evidence for WHO to inform a potential policy decision on global intermittent preventive treatment of malaria in pregnancy.

TIPTOP is also setting the stage for scale up, supporting Ministries of Health to pilot test SP distribution at the community level in settings that will not only yield quality data in real-life program settings but also lend to program learning, including documenting best practices and lessons learned. Further, in coordination with Medicines for Malaria Venture (MMV), TIPTOP is creating demand for and expanding access to QA SP.

Now that procurement, training, supervision, community education, monitoring and evaluation systems are nearly built, full implementation on the ground will be phased in over the next few months.

The preliminary 2018 Demographic and Health Survey (DHS) data have been released for Guinea (Conakry). Since the last DHS in 2012, Guinea and its neighbors experienced the largest Ebola outbreak in history, an event that damaged already weak health systems.

The previous DHS showed very weak malaria indicators. Only 47% of households had at least one ITN, which averages to 0.8 ITNs per person (compared to the universal coverage of 2.0). Among vulnerable groups only 26% of children below the age of 5 years slept under an ITN, as did 28% of pregnant women. Very few, 18%, pregnant women got two doses of IPTp, and only 5% of febrile children received ACTs (testing was not reported then).

Not much has changed concerning ITN coverage as reported in 2018. Slight improvements are seen in IPTp (which now requires 3 or more doses) and malaria testing and treatment for children. Ironically none of the indicators has passed the original 2006 Roll Back Malaria target of 60%, let alone 80% for 2010 and not of course the drive for universal coverage.

DHS has released a preliminary report for 2018 and the malaria component is summarized in the charts posted here. The national coverage for ITNs is 44%, slightly lower than 2012, but the average per household member is slightly higher at 1.1. Again, these numbers do not mark significant progress. Looking at wealth and ITN ownership there is a slight benefit in terms of equity in net possession among those with lower income, but this must be seen in the overall context of very low basic coverage.

Having a net in the household and using it are different challenges as seen in the reports of sleeping under the net on the night prior to the survey among children under 5 years of age and pregnant women. The sad finding is that even in households that own a net, the coverage of these two groups remains very low. This is reflected in the low net per person ratio nationally (1.1).

One would almost wonder if malaria is a neglected disease in Guinea. The reality is that since 2003, Guinea has received around $172 million US dollars in malaria project funding from the Global Fund. Its most recent annual funding from the US President’s Malaria Initiative (PMI) is around $14 million. Of that PMI funding 24% was designated for nets and related activities, while 52% was to be spent on medicines, diagnostics and pharmaceutical management. These investments include systems strengthening and capacity building in addition to commodities.

PMI provides the needed context: “Since the country was declared Ebola-free in in June of 2016, Guinea continues to make positive advances towards building a strong health system in line with the health recovery plan. The government continues to mobilize internal and external resources for rolling out the health system recovery plan, but much remains to be done if this plan is to yield the intended results.” Areas in particular need of strengthening within the National Malaria Control Program include coordination, health information systems, leadership, supervision and logistics.

Three years have passed since the last Ebola case in Guinea. Hopefully the country can stave off another outbreak and at the same time strengthen its health system. Guinea may not yet be targeted for malaria elimination, but until systems are strengthened, the resources going into malaria control will not be able to push malaria indicators toward saving more lives.

The full 2017 Malaria Indicator Survey (MIS) results have been published for Tanzania providing an opportunity to look at the findings in more detail. Several important factors need highlighting since Tanzania is part of a regional block where some countries are activly considering malaria elimination – the E8 countries of the Southern Africa Development Community.

So far Tanzania has come close to achieving a target of 80% of households owning insecticide treated nets (ITNs) with 78% on the mainland and 79% in Zanzibar. A closer look shows that there is still a ways to go to get to universal coverage or at least one net for every two persons in the household. With this indicator 45% of mainland and 42% of Zanzibar households have met the target, meaning that there are unprotected people in a majority of households across the country. This indicator experienced a drop from a 2011 “high” of 56%, a drop to 39% in 2015 and a slight recovery to 45% in 2017.

Even the universal coverage target requires that people actually sleep under the nets. What the MIS report shows is that although 63% of people had access to an ITN, only 52% reported sleeping under one the night before the survey.

Equity remains an issue with 69% of households in the lowest wealth quintile owning at least one net compared to 81% and 83% in the middle and fourth quintiles. Although households in the highest quintile had 78% ownership, this group is more likely to live in better quality housing that prevents the ingress of most mosquitoes. Also residents in urban areas have an edge over rural counterparts in terms of net access.

The report show that 55% of children under 5 years of age and 51% of pregnant women slept under an ITN. This is down from 72% and 75% respectively in 2011.

We learn that 90% of existing nets were obtained through some form of public sector campaign including mass distribution (62%), village coupons redeemable at health centers (15%), and school campaigns (4%). Only 5% were obtained through routine services (ANC, child immunization) indicating that efforts to ‘keep up’ after mass campaigns need to be strengthened. The 10% of nets, whether treated or not, that were obtained in shops and markets cost the owner in the neighborhood of US$5.00.

Uptake of doses of intermittent preventive treatment for malaria in pregnancy has slowly but steadily increased over the past 15 years and stood at 83% for one dose, 56% for two doses and 26% for three in this most recent MIS. With the current target being three or more doses needed for optimal protection, Tanzania still has a far long way to go, especially considering that accessing ITNs through ANC services is also low..

Jasmine Chadewa, Chonge Kitojo, Goodluck Tesha, Naomi Kaspar, Lusekelo Njoge, Zahra Mkomwa, Dunstan Bishanga, George Greer, Abdallah Lusasi, and Sigsbert Mkude of the USAID Boresha Afya Project, the US President’s Malaria Initiative, the National Malaria Control Program, and the Community Development, Gender, Elderly and Children (Tanzanian Ministry of Health) shared how malaria data quality could be improved at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene. Below are their findings.

Tanzania has a high malaria burden (see Figure 1) and is facing an increased demand for health services. The Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) developed the Malaria Service and Data Quality Improvement (MSDQI) checklist to guide supportive supervision teams in evaluating the quality of malaria case management (MCM) services at facility level. MSDQI helps with the collection, monitoring, and evaluation of facility-based malaria performance indicators at all levels of service delivery that provide timely, accurate information and data for decision-making at district, regional, and national levels.

USAID Boresha Afya conducted MSDQI assessments in 1,222 health facilities in the Lake and Western zones in outpatient departments (OPDs) and during antenatal care (ANC). The program disseminates malaria and ANC guidelines, tablets, job aids, and standard operating procedures. It also continues to facilitate supportive supervision and mentorship through the MSDQI tool to build providers’ capacity in identified areas.

Among the challenges reported, Supervisors need to be trained in more than one module to reduce cost. There is turnover of MSDQI supervisors. Cases that come back positive for diseases other than malaria are not investigated further. The use of Android smartphones sometimes interfered with data collection and the reporting system. • Regions/districts depend on donor support to implement MSDQI activities.

In conclusion, effective implementation of the MSDQI tool requires regions, districts, and facilities to be well informed and given clear instruction so they can form supportive supervision teams. This should be done by:

The team learned that MCM improved in OPDs and during ANC as a result of the MSDQI assessment. Improved access to quality MCM (diagnosis) nationwide. Frequency of malaria testing increased during the first ANC contact. Testing increased from 87% in April–June 2017 to 96% April–June 2018, a 9% change (see Figure 3). Second doses of intermittent preventive treatment of malaria in pregnancy (IPTp2) coverage increased by 15% on average in Boresha Afya-supported regions between October 2016 and June 2018 (see Figure 4).

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of USAID Boresha Afya and do not necessarily reflect the views of USAID or the United States government.

Maya Tholandi, Lolade Oseni, Anne McKenna, Herbert Onuoha, Solofo Razakamiadana, Elsa Nhantumbo, Alain Mikato, Elaine Roman of Jhpiego and the Johns Hopkins Bloomberg School of Public Health shared important Baseline Readiness Assessment Findings from Democratic Republic of the Congo, Mozambique, Madagascar, and Nigeria from the UNITAID-supported TIPTOP on Intermittent Preventive Treatment of malaria in pregnancy at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene as seen below.

Intermittent preventive treatment of malaria in pregnancy (IPTp) is unacceptably low in most of sub-Saharan Africa. A Jhpiego-led consortium is implementing the Transforming Intermittent Preventive Treatment for Optimal Pregnancy (TIPTOP) project, which supports community distribution of quality-assured sulfadoxine-pyrimethamine (SP).

TIPTOP aims to increase IPTp3 coverage from 19% to 50% of eligible pregnant women in project areas in Democratic Republic of the Congo (DRC), Madagascar, Mozambique, and Nigeria. The project, operating from 2017 to 2022, provides quality-assured SP, promotes community awareness, and supports supervision and coordination efforts between health facilities and community health workers (CHWs).

At project startup, the teams examined SP stock, ANC providers and CHW availability. SP Stock assessment showed a disparate stock maintenance processes and stock-out next steps indicate lack of a coherent and consistent approach to stock monitoring. In half of all cases, caregivers offer a prescription when stock is not available in the facility, with smaller numbers requesting.

Among ANC providers, 80% on average correctly reported that at least three doses of IPTp are recommended. On average, 64% correctly responded that SP should be initiated in the second trimester. Out of the 170 providers interviewed across countries, only five knew all the key signs of suspected malaria.

A low numbers of CHWs in some districts may limit their reach and capacity. Inadequate CHW education and ANC familiarity may diminish training effectiveness. In particular, low numbers of female CHWs may decrease community acceptance and pregnant women’s acceptability of receiving IPTp from CHWs.

Data Quality and Availability from the routine services would affect monitoring of interventions. Over-reporting of ANC contacts and IPTp service provision is a data quality challenge. The HMISs in Nigeria and Mozambique record IPTp3 provision, but only at the local level. Supervising facilities do not always review data before HMIS entry for accuracy.

Concerning Monitoring and Evaluation System Components, Mozambique’s HMIS is the strongest of the four countries in terms of linking to the national system, current tools and reporting forms available in the facilities, and providers reporting an understanding of indicators and data reporting processes. Nigerian facilities had limited knowledge of indicators and their definitions, despite this information being available in Federal Ministry of Health-provided registers. Madagascar struggled with indicator definitions and data management processes. DRC faced the most challenges: Tools and reporting forms were not available in health facilities, and there were limited monitoring and evaluation structures and processes.

In Conclusion, Results from the baseline assessment are Informing efforts to improve data quality and CHW facility data flow in TIPTOP implementation areas. There is need to strengthen ANC provider knowledge through TIPTOP-supported trainings. One also needs to address CHW variation by country and support health facilities to monitor their SP stock. These findings are being shared with ministries of health and key stakeholders to inform malaria implementation and data quality efforts.

IMC together with the National Malaria Control Program has been strengthening Health Care Provider Capacity. 54 health districts have been covered by IMC direct support where 1819 providers were trained. Training reached 185 trainers/supervisors on revised training Modules who then trained 1,819 health care providers from 1,349 health facilities in 54 districts on new guidelines

IMC Strengthened National Malaria HMIS. This included training 1,300 (72%) health workers to enter data into monthly reporting forms. Also trained were 326 data managers on HMIS and data use for decisionmakers. The malaria data collection system was integrated into national HMIS using DHIS2. To facilitate this the national HMIS manual was revised and distributed. Data Quality was improved through malaria data review and validation at district levelUltimately these interventions resulted in Improved Malaria Services. More confirmed simple malaria cases received artemisinin-based combination therapy (65% in 2013 to 90% in 2017). More women received three doses of IPTp3 (14% in 2014 to 51% in June 2018). More suspected cases tested for malaria (65% in 2013 to 96% 2017). More women received insecticide-treated nets at antenatal care. There was Better accuracy in reporting of malaria key indicators.

Improved services led to decreased national malaria fatality rate. In the General population there was a decrease in malaria deaths of 34% and a decrease in overall fatality rate by 47%. Among pregnant women there was a decrease in malaria deaths by 91% and a decrease in malaria fatality rate by 93%. For Children under 5 years of age, there was a decrease in malaria deaths by 34% and a decrease in fatality rate 48%

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under Cooperative Agreement No. AID-624-A-13-00010 and the President’s Malaria Initiative (PMI). The contents are the responsibility of the authors and do not necessarily reflect the views of USAID, PMI or the United States Government.

Among the poster presentations on malaria from Jhpiego, the President’s Malaria Initiative and partners at the 2018 ASTMH Annual Meeting, WR Brieger, J Tiendrebeogo, O Badolo, M Dodo, D Burke, K Vibbert, SJ Youll, and JR Gutman shared the findings from a 15-month intervention that tested the ability of community health workers to deliver intermittent preventive treatment of malaria in pregnancy in 3 districts in Burkina Faso. Please check out the poster and talk to one of the co-investigators at Poster Session A on Monday 29 October. Their results are found below.

Malaria in pregnancy is responsible for a substantial proportion of low-birthweight and stillborn infants in sub-Saharan Africa. To prevent this, the World Health Organization (WHO) recommends that pregnant women receive intermittent preventive treatment of malaria in pregnancy (IPTp) using sulfadoxine-pyrimethamine. Specifically, WHO recommends an optimal three or more doses (e.g., IPTp3, IPTp4).

In stable malaria endemic countries, IPTp coverage remains unacceptably low, at around 19% for IPTp3. Community IPTp might provide an answer. Community delivery can improve coverage as seen in previous study in Nigeria and Malawi, but its effects on antenatal care (ANC) attendance have been mixed. Additional data are needed to determine whether delivery of IPTp-SP by community health workers (CHWs) is effective and does not detract from ANC attendance. Hence the Burkina Faso intervention was designed and implemented

The study piloted community delivery of IPTp (c-IPTp) in three districts of Burkina Faso with high malaria transmission: Po, Ouargaye, and Batie. Four health facilities per district were randomly selected to participate (two intervention and two control).

In 2017, following a baseline household survey of women who recently became pregnant, implementation of c-IPTp began in intervention areas by existing CHWs trained and supervised by health staff. At Baseline in each of the three study districts, four health centers (CSPSs) and the villages in their catchment areas were selected—two as intervention and two as control. A random sample of 374 women who had been pregnant within the last 9 months were interviewed in CSPS catchment villages. There were no significant differences in ANC attendance (ANC1=90%, ANC4=62%) or IPTp coverage between intervention and control areas:

IPTp3 was 81% (intervention) and 86% (control).

IPTp4 was 22% (intervention) and 16% (control).

The Intervention consisted of building on Burkina Faso’s existing CHWs. They were trained and monitored by clinic staff. The CHWs encouraged women to attend the first ANC visit to obtain IPTp1. Then the CHWs provided monthly doses of IPTp, submitted monthly reports, and continued to promote ANC. ANC attendance and IPTp uptake were monitored through monthly clinic and CHW reports. The catchment area populations were roughly the same, and monitoring showed that the additional provision of IPTp by CHWs resulted in more women being reached while at the same time ANC attendance remained high.

An endline survey was conducted after 18 months of implementation. Changes over time were compared between baseline and endline in intervention versus control villages. Attendance at ANC1 and ANC4 increased in both groups between baseline and endline but was significantly better for the intervention group. Likewise, coverage of IPTp3 and IPTp4 increased between baseline and endline for intervention and control women, but the difference was significant only in the intervention areas.

Monthly monitoring of CHW and ANC registers and the household surveys both documented that community delivery of IPTp resulted in the desired increased uptake of services without detracting from ANC attendance. Community IPTp may be a promising strategy to improve coverage of IPTp.

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.

The challenges of implementing programs to control malaria in pregnancy based on experiences with US President’s Malaria Initiative Countries was presented at the Malaria World Congress in Melbourne this week. The team included Katherine Wolf, MCSP/Jhpiego, Marianne Henry, PMI/USAID, Lia Florey, PMI/USAID, Gabrielle Conecker, MCSP/Jhpiego, Betsy Hendrickson, MCSP/Jhpiego, Katherine Lilly, MCSP/Jhpiego, Nicholas
Furtado, GFATM, Maria Petro, GFATM, Susan Youll, PMI/USAID, and Julie Gutman, PMI/CDC, and their findings are shared below.

What is the danger of malaria in pregnancy (MiP)? Each year MIP is responsible for 20% of stillbirths in Sub-Saharan Africa, 100,000 Newborn deaths globally, 11% of newborn deaths in Africa and 10,000 maternal deaths globally. Four interventions are aimed at MIP, Intermittent Preventive Treatment in Pregnancy (IPTp), consistent use of insecticide treated nets, effective diagnosis and treatment and low-dose folic acid during antenatal care. IPTp with sulfadoxine-pyrimethamine reduces low birth weight by 29%, severe maternal anemia by 38% and neonatal mortality by 31%. What can be done?

Scale-up and full coverage of the WHO lifesaving interventions

Promote early and regular ANC

Preserve SP efficacy by avoiding its use for treating clinical cases of malaria

Reserve SP stocks for IPTp at ANC clinics

Methodology for MiP country review: Initial survey took place in 23 PMI countries. PMI resident advisors were surveyed, Qualitative and quantitative responses were collected and Input from NMCP/partners was obtained. Country selection resulted in 12 that were Tiptop-implementing countries, represented Geographic diversity, had varied IPTp coverage, and made clear progress or best practices to share.

Desk review including HMIS and house hold survey data, current studies and recent assessments, Selected interviews with PMI resident advisors, Jhpiego field staff and current/former NMCP staff. Analysis was a Review and clarification of qualitative and qualitative data.

The 12 countries included Angola, Benin, Burkina Faso, DRC, Ghana, Kenya, Liberia, Madagascar, Malawi, Nigeria, Senegal, and Zimbabwe (see map). The figure shows that none of these attained 80% of 2 doses of IPTp. The current recommendations are for monthly dosages from the 13th week of pregnancy. Often less that half of those receiving IPTp2 also got IPTp3.

Several health systems findings helped explain the IPT results. For Policy & Implementation, Countries reporting strong, coordinated leadership delivered
high IPTp coverage. With Community Engagement, countries reported a diversity of approaches to community health promotion and service delivery.

Concerning Service Delivery, Many countries struggle to implement MiP policies consistently and with quality in the private sector. Commodities were a challenge. Some countries continue to struggle with SP stockouts at facility level, whether ongoing or episodic. Monitoring and Evaluation processes need to catch up. Countries’ routine information systems are transitioning from tracking IPTp2 to IPTp3.
The team offered several Recommendations.

For more information please visit www.mcsprogram.org, facebook.com/MCSPglobal and twitter.com/MCSPglobal

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative AgreementAID-OAA-A-14-00028. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the United States Government.

Intermittent Preventive Treatment of malaria in pregnancy (IPTp) using sulfadoxine-pyrimethamine (SP) has been a long standing intervention to protect pregnant women and their unborn children from the dangerous effects of malaria in stable transmission settings. Placental malaria deprives the fetus of nutrients leading to low birth weight, still birth and miscarriages. The mother herself suffers anemia and potentially, death.

There had always been a challenge to getting pregnant women to obtain at least two doses of IPTp-SP due to a variety of factors ranging from health system lapses to late antenatal care attendance by mothers. This phenomenon of dropping out of multi-contact interventions is not uncommon and seen equally in programs such as childhood immunization. Therefore when the World Health Organization raised the bar and recommended IPTp starting in the 13th week of pregnancy and monthly thereafter, the challenge of providing three or more doses arose.

The Malaria Indicator Surveys (MIS) and the Demographic and Health Surveys (DHS) are an ideal was to trace the progress of malaria intervention over multiple years. With the release of the preliminary results of 2017 Tanzania MIS it is now possible to track this service from over a decade. The Attached chart, using MIS/DHS reports shows that so far Tanzania has not come near achieving 80% coverage of this indicator. While there had been major increases over recent years, reports of IPTp coverage in 2017 show only 56% of recently pregnant women received at least two doses, and only 26% received three or more.

It should be noted that countries are beginning to stratify their interventions according to available transmission data. Therefore as noted in the US President’s Malaria Initiative Malaria Operations Plan for 2018, Zanzibar where transmission is low, has stopped IPTp and focuses on prompt and appropriate case management, while the mainland of Tanzania continues with all MIP interventions. Of interest is the most recent child prevalence map found in the 2017 MIS results that shows other parts of the mainland may also be approaching very low transmission.

Moving forward it will be useful if Tanzania and other endemic countries not only gather epidemiological data to help stratify appropriate interventions (as suggested in the WHO malaria elimination framework), but go further to focus reporting by strata. That said, the health system and community difficulties in achieving high IPTp coverage wherever it is appropriate will remain a challenge if services remain based in static health facilities. Community roles must be explored.

https://t.co/yKKsmAEpSv @MinSanteRDC #Ebola 23 May 2019: Since beginning of epidemic, cumulative number of cases is 1,888, of which 1,800 confirmed 88 are probable. In total, there were 1,254 deaths (1,166 confirmed and 88 probable) and 492 people cured. 11 new confirmed cases